Good book. This is really two books, spliced together: one is about the opiate scourge and how Purdue Pharma and many "pain doctors" across the country took maximum advantage of changing medical mores on pain treatment; the other is about a small state in Mexico that improbably dominated the transport, distribution and direct sale of black tar heroin to second- and third-tier cities across the USA.
It's also a book about how we are a lost people in a deeply decayed society.
History rhymes, and this book rhymes with what's going on right now: If you believe that there's something not quite right, something "off" right now in healthcare--with divisive mandates, with the strange embargoing of early treatment options for COVID, with the wide prescribing of enormously profitable but clinically suspect new meds like paxlovid and remdesvir--this book will show you similar widely institutionalized practices that were likewise "off" and not right during the peak of the opioid epidemic.
Notes:
1) The Porter and Jick letter, a textbook example of how a statistical lie becomes a truth through citations, citations of citations, and citations of citations of citations; a circle-jerk of "evidence" that addiction is rare in patients treated with narcotics.
2) Arthur Sackler and innovations in pharmaceutical marketing and advertising. Later Sackler goes on to found Purdue Pharma.
3) "In heroin addicts, I had seen the debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man's decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior." A useful quote here that conveys why life requires adversity and (sometimes) pain, see also the Buddhist concept of samsara.
4) The "Xalisco Boys" of Xalisco, Nayarit State in Mexico: peaceful, hard-working, service-first, local delivery guys for black tar heroin, selling to white customers only.
5) A heroin addict as the ultimate of all "sticky customers," a business model that lends itself to structured underworld business.
6) Methadone clinics ironically become like "game preserves" for the Xalisco boys, a ready market of future clients: find the methadone clinic, give away free samples to the methadone addicts and you have an easy automatic market in a new city.
7) The Xalisco delivery model was much better from a law enforcement perspective, hours of surveillance would yield very few drugs, good cases were hard to put together. Drivers were deported and rarely prosecuted because they carried small amounts. It was a sophisticated (even decentralized) response to the law enforcement "marketplace" where prosecutors wanted large quantities of "dope on the table" whereas the Xalisco Boys model was just-in-time with small quantities.
8) Pain management in medicine as a sort of pendulum, swinging too far each time: from a 1920s-era fear/loathing of opiates and addiction which drove a generalized resistance to treating pain (which meant patients died in agony) to an institutionalization of "pain management" and palliative care, to then progressing to the extreme of prescribing pain meds to too many people for too many reasons.
9) "I found at least two studies that showed that prescribing of all kinds rose as doctor visits shortened.... As every doctor knows, nothing cuts short a patient visit like a prescription pad."
10) The Porter and Jick letter led to a universally believed claim that less than 1% of patients treated with narcotics developed addictions... Not unlike the claim that mRNA therapies were 95% effective and safe... "We all used it [the claim]. We all thought it was gospel." And yet Porter/Jick wasn't even a study!! It was just a letter to the editor in a medical journal, and it became new conventional wisdom.
11) Reminds me of the citation ring phenomenon in Wikipedia where false things become "true" simply because they appeared in mainstream media somewhere and were thus citeable.
12) Heroin sold at cheaper economics and higher volumes for people with less money, using a complex, semi-decentralized system.
13) Also the Xalisco heroin has much higher purity too: nobody "steps on" the heroin because it's not repeatedly resold! 80% pure rather than the more typical 12%, 6x more. Thus "you could maintain a moderate heroin habit for about the same price as a six pack of premium beer."
14) Pain becomes a "vital sign" in health care.
15) Good example here of regulatory capture: one of the major regulators of Oxycontin ended up working for Purdue Pharmaceutical, the maker of that very drug...!
16) The FDA warning on Oxycontin said patients should not crush the tablets, which was precisely what addicts would do to maximize the dosage over the short term. At the same time, Oxycontin was "proven" to be addictive in less than 1% of pain patients per the endlessly cited Porter and Jick letter.
17) I wonder to what extent we will see parallels in this book with what's happening in COVID treatments and mRNA injections today: first a movement with a lot of force and velocity then an equivalently forceful backlash. See the arc of Purdue Pharma's incredible economic success, big sales rep bonuses, Oxycontin grew to make up 90% of the company's total revenues; furthermore, Purdue's lawyers began harassing doctors for publicly making comments that Oxycontin might actually be addictive... ultimately crashing to where the US gov't ultimately filed criminal charges and levied tremendous fines against Purdue for harms done.
18) If a study suggests a finding "X" [e.g.: "opioids are addictive in only 1% of cases" or "ivermectin is not efficacious in managing COVID"] but hundreds or even thousands of examples of field medicine show finding "not X" [e.g.: "many of my patients are becoming opioid addicted" or "ivermectin is efficacious in managing COVID"] which, then, is true?
19) Addiction via "pill mill" doctors, see Portsmouth, Ohio's Dr. David Procter as a textbook example. Tying together the unemployment of a deindustrialized Midwest, the samsara and despair of not having much in terms of economic prospects, the possibility of getting on disability and thus getting a free monthly government check. And if you have or even claim to have "pain" of any sort it could be waved away with a Vicodin, a Lorcet or Oxycodone prescription. This became an economic strategy for many people.
20) The sentence gave me a bit of a grammar boner: "When you deal with people who are in pain all day long, after a while you get worn down." Wait: are you dealing all day long with people who are in pain, or are you dealing with people who are in pain all day long?
21) Oxycontin was basically pharmaceutical grade heroin in a form that could be crushed and which would likely quickly addict anyone who used it--despite the conventional wisdom that it wouldn't. Further, as it was regulated as a Schedule II narcotics, getting an Oxycontin script required a monthly office visit. So now the pill mill doctor has his own "sticky customers."
22) Dr. David Procter also had "disciples" in a way, hiring doctors to work for him, and some of them relocated elsewhere using his business model. Procter frequently saw 146 patients a day (!!!), with lines out the door, averaging a 3-minute appointment each, at $200 cash for an office visit. This was the business model for the pain clinic.
23) The author ties the book's two threads together by trying to make the case that Oxycontin addicts were black tar heroin junkies in waiting, that by selling Oxycontin Purdue Pharma "tenderized" the country for heroin addiction.
24) It was some 20 years before the federal government and the DEA caught on to the scale and scope of the Xalisco Boys' operation.
25) The major DEA operation to attempt to unravel this organization was called Operation Tar Pit, culminating in a seizure of 60 lb of heroin and $200,000 cash, a pathetic haul despite being the largest case (geographically and in terms of manpower use) by the DEA and FBI in a joint drug operation. The author doesn't say this, but one way to look at this is to see that clearly it wasn't worth it to go after these guys. And because of the Xalisco Boys' decentralized structure, the business quickly got up and running all over again. The federal case did nothing.
26) "Dr. Katz? Nathaniel Katz? I've been waiting for 10 years to tell you this. You killed my brother, Peter." A pain specialist doctor has his eyes opened to the dangers of prescription opioids.
27) When you see a radical change in the conventional wisdom in medicine--like the changed medical consensus on treating pain--one can't help but wonder what current consensus beliefs of medicine are about to change. What therapies or meds will be debunked, thought of retrospectively as medieval, etc? Half of all scientific beliefs are wrong, we just don't know which half...
28) This quote from Dr. Katz as he explains his personal change in opinion is a good example of how skilled doctors can be... at following orders! "My fellowship director even told me, 'If you have pain, you can't get addicted to opiates because the pain soaks up the euphoria.' Now you look back and it sounds so preposterous. That's actually what people thought.... But, young and dutiful, Katz prescribed opiates." He knows now that it was the wrong thing to do but he certainly followed orders back before he knew.
29) And then the beginnings of the turning of the tide: in May 2001, attorney Joe Hale in Southern Ohio filed the first wrongful death lawsuit against Purdue Pharma, initiated on behalf of a client's daughter who died injecting crushed Oxycontin; later he represents a class of victims but the case was ultimately dropped. Then, nothing happened for a while on the legal front until more famous people started dying.
30) Finally an official inside the State of Washington's Workers Compensation System started to see "died suddenlys" in the states database of deaths... She put two and two together, culminating in the Franklin and Mai paper published in the American Journal of Industrial Medicine.
31) If you are on SSI (Social Security Disability) and you have a Medicaid card, you can have most of your pain meds taken care of by the taxpayer. Better still, you can resell half of those pain meds, leaving enough for yourself, and earn quite a good living.
32) Quite sophisticated secondary markets start developing in Oxycontin as well as other pain meds. There is even a secondary market for "clean" urine for people to use to pass drug tests. See also secondary markets for shoplifted Walmart products, and even of discarded Walmart receipts (!) that could be used with matching freshly stolen items, which could then be returned and exchanged for cash.
33) The framing of Walmart as a haven for shoplifters such that it actually partly drove a "pill economy"... this story sounds pretty implausible; it sounds like more of an amplified figment of the imagination of somebody who really dislikes Walmart.
34) It wasn't until 2006 when the first case of criminal misbranding was filed against Purdue Pharma, some 15 years after this whole thing got started.
35) A conspiracy of silence among middle class and upper middle class Charlotte North Carolina parents: it was unbecoming to have your son die "suddenly" or "unexpectedly" with a needle in his arm. Police and other advocates pleaded with parents to come forward and tell their stories, none did.
36) The parallels of that era's data on overdose deaths with today's mRNA safety data are quite striking: strong (even overwhelming) statistical evidence of skyrocketing overdose deaths, but doctors who are treating their patients for chronic pain, don't see it on the anecdotal level (and more importantly don't want to believe it). !!!
37) See Washington State's Labor and Industries Department trying to convince doctors to limit opiate prescriptions. The doctors' pushback was that "the government should not meddle in medicine." Hmmmm...
38) "We asked them, this is your specialty. At what dose do you say, I need to step back and reevaluate this patient because this may not be working?" See today: how many iatrogenic deaths are required to determine that remdesvir is not indicated? Or: How many deaths among young people do you need to see before we hit a stopping condition for university and other vax mandates? History rhymes.
39) What a striking chapter about the Russian Pentacostals in the Western United States. This is a frightening example of an accelerated corruption of an innocent culture via modern media, modern pharmaceuticals and illicit drugs. All the sins of modern society conspire together to destroy it almost as if they were there by device! The parents and family members either were oblivious and didn't know about it, or ashamed and silent because they did know about it; either way they kept everything hidden. Makes you realize why crises like this are simply not talked about. Also when a consensus about a given med begins to evolve, for example when a med is found to be more dangerous than originally thought, word does not get out until too late for many people.
40) The book at times is rather repetitive: the reader is reintroduced more than once to many characters later in the book, see for example the former professional wrestler (and later pain management textbook writer) Dr. John Bonica.
41) "Talk therapy is reimbursed at fifteen dollars an hour, but for me to stick a needle in you I can get eight hundred to five thousand dollars. The system values things that aren't only not helpful but sometimes hurtful to patients." This is a tremendous structural problem with medicine as a discipline.
42) There was even drama about the first federal prosecution of Purdue Pharmaceutical: prosecutor John Brownlee was asked by the US DOJ to postpone a plea agreement that he had worked out with Purdue, as his name had shown up on a list of federal prosecutors recommended to be fired under the Bush Administration, Brownlee alleged that this was political retaliation. Eventually Purdue Pharma pled guilty to a felony count of misbranding Oxycontin, paying a $634 million fine. [Later the company collapsed into bankrupcty under a tsunami of lawsuits.]
43) The book's main conceit (that Oxycontin "tenderized" a generation of folks for opiates) doesn't seem to make sense when it's mostly young white kids who are buying the black tar heroin sold by the Xalisco boys, and it's unemployed older/disabled people who are primarily using Oxycontin. No matter how many times the author says "Oxycontin tenderized the market" it doesn't make it true.
44) "To even see the plague required examining confusing and incomplete data." Plus the silence of families ashamed of their child's death. I wonder how much of this opiate-era history will be seen to "rhyme" with today as we look back on the aggressive peddling of mRNA and related therapies.
45) Dr. Alex Cabana takes over the Holistic Pain Clinic, but while overworking, goes from 260lbs to 305lbs, and lives on a cocktail of meds: hypertension, cholesterol, taking nine meds a day, he can barely walk up two flights of stairs, etc... basically this is a doctor so overworked at a pain clinic that in some ways he begins living like an addict too!
46) "My instructors told me that when you take opioids for pain you can't become addicted because the pain absorbs the euphoria. That was at Harvard medical school. It was all rubbish, we all know now. Why do we listen to those messages? Because we wanted them to be true." Dr. Nathaniel Katz again (see note 26 above), the Boston pain specialist, grappling with why he was wrong before in his views on pain care and opioids. We can easily identify when we were wrong about something in the past but we rarely have epistemic doubt about what we might be wrong about right now. The more I think about this risk the more traumatized I am about all my decision-making. Worst of all, it is deeply traumatizing to think about any decision that I might outsource to "experts" who are never traumatized by this risk, and in fact don't bother to think about it at all on my behalf.
47) "One way to view all that had happened was as some enormous social experiment to see how many Americans had the propensity for addiction." Turned out that a lot of us did.
48) Portsmouth, OH as a type of microcosm for the USA, slowly emerging from the "mass formation" of opiate addiction and gradually rebuilding itself.
49) Many in middle America were "nudged" into addiction by a collection of forces and incentives. People move, act and think in herds, and the herd has a gravitational force that can pull, strongly, on even the most individualistic members in it. Also, critically, you have to have some level of silencing, shaming or suppression/censorship of victims in order to have a negative system like this perpetuate itself. Once again, I wonder how much of what is happening today will "rhyme" with the opioid era.
To Read:
Martin Booth: Opium: A History
William S. Burroughs: Junky
Lois A. Reynolds: Innovation in Pain Management
Larry Meier: Pain Killer